(A) Purpose
The purpose of this rule is to implement the open enrollment
statute, sections 3923.58 and
3923.581 of the Revised
Code. This rule requires
carriers to provide information to consumers, insurance agents and to the
superintendent, pursuant to section
3923.582 of the Revised Code.
The open enrollment requirements in this rule apply to any carrier that is in
the business of issuing health benefit plans to individuals and/or non-employer
groups.
(B) Authority
This rule is promulgated pursuant to the authority stated in
sections 3901.041 and
3923.582 of the Revised Code.
Pursuant to section 610.53 of
Amended Substitute House Bill 49 of the 132nd General Assembly, during
the period beginning on January 1, 2014, and expiring
January 1, 2022, the operation of sections
3923.58,
3923.581 and
3923.582, of the Revised Code
are suspended. As a result, carriers shall not be required to offer open
enrollment coverage under the "Ohio Open Enrollment Program" on or after
January 1, 2014. Therefore, during the period beginning on January 1, 2014, and
expiring January 1, 2022, the operation of this rule also is
suspended. If the amendments made by
42 U.S.C.
300gg-1 and
300gg-6,
regarding the requirements related to health insurance coverage,
become ineffective prior to the expiration of the suspension of
January 1, 2022, then sections
3923.58,
3923.581 and
3923.582 of the Revised Code and
this rule, in either their present form or as they are later amended, again
become operational.
(C)
Advertisement of open enrollment coverage
Carriers subject to the requirement to provide open enrollment
coverage under sections
3923.58 and
3923.581 of the Revised Code
shall comply with the following steps by the dates specified.
(1) Each carrier shall provide to the
superintendent by November 1, 2009, a toll free number that will be used to
accept public inquiries on open enrollment coverage. The carrier shall make
this number available to the public, beginning December 1, 2009.
(2) The toll free number will be answered
during the carrier's normal business hours.
(3) Each carrier shall develop a web page, by
January 1, 2010, providing notice of the availability of the open enrollment
coverage being offered pursuant to the terms of this rule. The open enrollment
web page must be easily accessible to visitors to the home page of the
carrier's web site.
(4) The web
page shall include a table of premium rates to enable a consumer to calculate
the maximum premium that would be charged to a person of the same age, gender,
geographic location and plan selection.
(5) The web page shall be available at all
times and kept as current as possible.
(6) A carrier shall inform an applicant that
has been denied other health coverage by that carrier of the availability of
open enrollment coverage with that carrier.
(7) Each carrier shall make coverage
applications available online for consumers or insurance agents to fill out or
print and mail to the company. Carriers shall also provide an online contact
person who shall answer queries within two business days.
Carriers must notify applicants, or their agents of record, of
the acceptance or rejection of their application within five business days of
receipt of a completed application. Carriers may adjust the terms of coverage
as necessary in the event subsequent receipt of relevant documents requires. If
the carrier offers coverage subject to a waiting period under section
3923.581 of the Revised Code,
the first day of the waiting period shall be the date of receipt of the
completed application. No carrier may require enrollment to be made in person.
Carriers may accept applications for coverage online, by phone or by mail. A
representative of the carrier may contact an agent or applicant who has
submitted an application in order to explain the operations of the carrier and
to answer any questions the agent or applicant may have. Every carrier shall
make open enrollment applications and solicitation documents readily available
to any potential agent or applicant who requests such
material.
(8) The following
information shall be made available on the carrier's web page:
(a) Open enrollment will begin on January
first of each year and will remain open until the carrier has reached its
statutory limit;
(b) A clear
explanation of "Federally Eligible Individuals" ("FEI") and non-"FEI"
individuals including the eligibility requirements for each open enrollment
product offered by the carrier; the differences between the "Basic" and
"Standard Plan" and any other open enrollment coverage offered. A carrier may
use appendix "A" to this rule to satisfy this requirement;
(c) Under what circumstances an eligible
applicant or the applicant's dependents may be subject to a preexisting
condition limitation;
(d) The
address and web site where a person may obtain an application, if different
from the open enrollment web site;
(e) The telephone number that a customer may
call and hours of operation and an e-mail address in order to request an
application or to ask questions;
(f) The date the first payment will be
due;
(g) A rate calculator or a
page that would allow a consumer to calculate the actual or maximum premium
that would be charged to a person of the same age, gender, geographic location
and plan selection; if the rate provided is the maximum rate, the web page
shall explain in what circumstances the actual rate will vary;
(h) Information regarding the carrier's
waiting list, if the carrier maintains one; the process of getting on the
waiting list; and the process by which the carrier shall notify applicants of
enrollment decisions.
(9)
Information regarding open enrollment must be easily accessible to callers of
the toll free telephone number. Persons answering the toll free telephone
number must be adequately trained and informed about the open enrollment
process. In addition to the information required in paragraph (D)(8) of this
rule, persons answering the toll free number must be able to answer customer
questions and provide the actual rate, or the maximum rate, that will be
applicable to the eligible applicant for all open enrollment products offered
by the carrier.
(10) No carrier may
employ any scheme, plan, or device that restricts the ability of any person to
enroll during open enrollment.
(11)
The carrier shall electronically certify on a form prescribed by the
superintendent if and when it has met the enrollment limit. In addition, the
carrier shall provide a status update to the superintendent with regard to any
waiting list, if the carrier maintains a waiting list, on the fifth business
day of the month for the previous month. The status update must also report
when the carrier reopens enrollment in order to maintain its enrollment limit.
A carrier that does not maintain a waiting list must explain to the
superintendent how it will maintain its enrollment limit as current enrollees
drop off.
(12) The superintendent
will provide on the department of insurance web site a common access point for
open enrollment information. The following information may be included:
(a) Carriers' toll free numbers;
(b) Links to carriers' open enrollment web
page;
(c) Whether a carrier's open
enrollment program is open or closed;
(d) Other information as the superintendent
deems appropriate.
(D) Reporting and data collection
requirements for open enrollment
(1) Carriers
subject to the requirement to provide open enrollment coverage under sections
3923.58 and
3923.581 of the Revised Code
shall provide data to the superintendent as requested.
(2) Carriers are requested to file the data
that is enumerated in divisions (C)(1)(a) to (C)(1)(c) and (C)(1)(e) of section
3923.022 of the Revised Code. It
should be separately reported for the carrier's non-open enrollment policies
and the open enrollment policies. This data should include:
(a) The amount of premiums earned by the
carrier both before and after any costs related to the carrier's purchase of
reinsurance coverage;
(b) The total
amount of claims for losses paid by the carrier both before and after any
reimbursement from reinsurance coverage;
(c) The amount of any losses incurred by the
carrier but not reported by the carrier in the current or prior year;
and
(d) The amount of costs
incurred by the carrier for reinsurance coverage.
(3) Carriers are to report this data
electronically for calendar year 2009 and every year thereafter. The non-open
enrollment policies include coverage sold to individual insureds or enrollees
and non-employer group insureds or enrollees in this state. The open enrollment
data should be reported separately for "Federally Eligible Individual" policies
and non-"Federally Eligible Individual" policies. "Federally Eligible
Individual" has the same meaning as in section
3923.581 of the Revised
Code.
(4) Carriers shall file this
data electronically by April first of each year, starting with April 1, 2010.
(E) Severability
If any paragraph, term or provision of this rule is adjudged
invalid for any reason, the judgment shall not affect, impair or invalidate any
other paragraph, term or provision of this rule, but the remaining paragraphs,
terms and provisions shall be and continue in full force and effect.
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Appendix